Part 5

What is to be expected of the chief in the way of research? One hears a great deal about research ability as a qualification for the professor of medicine and about the necessity of his carrying on research personally while he occupies the position. Capacity for high grade research is so rare a quality in itself that it will always be almost impossible to find it combined with the other qualifications demanded of a professor of medicine. Ability to do good, conscientious, independent work, interest in stimulating and assisting others to carry on research, and an appreciation of the rôle that research plays in the medical clinic are more important than great personal research genius. The professor must keep in close touch with the work of his staff, guiding where he can, suggesting and encouraging, and he should always try to keep up some independent work if only for his own intellectual satisfaction, so that he may set an example to the staff and may have some little field in which he excels his assistants. Even if he had great ability as an investigator he could not expect to accomplish much, as the multifarious demands on his time make it almost impossible to obtain the sense of leisure which thoughtful work requires. Indeed, I feel that if a man really has this rare gift he ought not to be the head of a department of medicine lest his talent be wasted.

One may reasonably question whether the large proportion of the budget of the department of medicine that is devoted to research and the great stress that has been laid on research ability in the selection of teachers is entirely justified, when one considers that much of the research output is of a routine nature and that really significant research is unusual. My personal feeling is that it is justified, although I think the pendulum has swung too far in the matter of choice of professors. Here there is a very unfortunate tendency to pay too little attention to broad clinical experience, something that is acquired only by many years of hard work and too much attention to research ability, or, what is worse, to the possible development of research ability in some promising young man. The publication of a number of good papers does not really indicate any marked capacity for investigation, and such papers certainly offer limited evidence of ability to run a department of medicine. Even in the preclinical laboratories and research institutes the proportion of research that is very noteworthy is not always particularly high, and, when one considers all the other functions required of the men in the department of medicine, I think that we may be rather proud of what they are accomplishing.

There is a common tendency to attempt to select assistants in a department of medicine whose training represents the different preclinical sciences, physiology, organic chemistry, physical chemistry, physics, bacteriology, so that one may have a well rounded clinic. There is obviously much to be said in favor of such a plan as it helps to bring together an experienced group of “scientists”; but there is also an inherent practical danger which I am sure we all have observed and to which more attention should be paid. These men, thoroughly trained in one direction, quite naturally look for their research problems in the fields in which they are trained. They seek the problem to suit their particular tools. This must necessarily be the attitude of workers in a fundamental science when they attempt to study a clinical problem, and this may explain why they often are not more successful in formulating and working out problems involving a knowledge of disease in man. The approach of the internist to the study of disease in man should be quite different. He is, first of all, absorbed by an interest in the problem and then seeks the type of tools necessary to solve it. This is the intellectual, rather than the technical, method of approach. Once given an absorbing passion for the solution of a clinical problem, the man who has a good, general scientific training can usually acquire in a few months or in a year or so enough of any of the fundamental sciences to enable him to tackle it. The clinical investigator, with his knowledge of disease in man, thus finds the problem first and determines the practical way to study it, turning to his colleagues in the fundamental sciences especially for technical experience. We often discuss what the difference is between the function and opportunity of the man who is primarily a “scientist” working on a clinical investigation, and the man who is primarily an “internist” using methods of exactly the same highly refined nature, and also working on the same general type of investigation. The real difference is, I think, to be found in the point of view. The medical clinic should encourage its staff to use methods of any sort, no matter how difficult or specialized, that are needed for the solution of their immediate problems; but their first interest should center about the general subject of disease in man. The first interest of the “scientist,” on the other hand, is in the development of his own particular field. Each has his proper rôle, but in the medical clinic it is better to have an inspired “internist” than a skilled “chemist.”

The administration of a department of medicine, with its complicated relationships and responsibilities toward a large group of various types of men, to the students of three classes, to interns, to the medical school administration with all its subdivisions (wards, social service, outpatient department, dietetics and other clinical departments), to patients and their families, and to laboratories, represents a problem which is unapproached in any other department of the medical school with the possible exception of that of surgery. One frequently hears it said that if the chief is a good administrator he will divide all this work up and put it on the shoulders of his assistants. To a certain extent this is possible and is, indeed, absolutely necessary; but experience has shown me that beyond a certain point it is unwise to do so and that the major part of the administrative responsibility must be assumed by the chief. The representatives of the medical school, the superintendent of the hospital, the chief of the roentgen-ray department, the assistant in charge of the chemical laboratory, all want to deal directly with the chief; and the smooth running of the clinic demands that they shall. But to my mind it is not only to these dignitaries that the chief must leave his door ajar. How often one finds interns and students lurking outside the office, waiting to catch the chief as he hurries by. “Can I have five minutes with you, sir?” You let him in, sit down, and find that what he has approached so modestly is the problem of his whole career; and who can tell whether it may not be a career with very significant possibilities? Is there, on the whole, anything more important than giving advice about a man’s life? Of course, a first class administrator might say, “Tell him to return next Tuesday at 2:30, at the time appointed for such conferences.” All right; but usually the youth has worked himself up and is full of his problems now, and it is now that you can help him most. We hear a great deal about the necessity of the professor “closing his door” and “protecting himself.” I fear that some of this “protection” is made necessary by the fact that our professors are apt to be rather inexperienced, and they have to get their training after they get their job. The real question is whether the professor ought to devote himself to looking after his own career or whether he ought to regard as his first duty that of stimulating, helping and advancing his assistants. Of course, this is largely a question of personality; but there are so few men whose research ability is extraordinarily valuable (and, as I have said, they ought not to be professors of medicine) that I believe in general in the “open door policy.” This is, at any rate, the policy that best suits my temperament and capacity. I have always attempted to keep some of my own work going, partly through assistants, and, so far as I can, with my own hands (although this comes more and more to what can be done in the summer vacation) for this is what keeps me alive intellectually and is where I get my real fun. On the other hand, I feel that probably I accomplish most in the long run, not by protecting myself too closely, but by accepting as my major function that of helping my students and assistants. Much greater contributions to the advancement of medicine will come from the training of these men than through my own individual efforts.

In all this lengthy letter I do not think I have once used the phrase “full-time” as applied to a clinic or a teacher. This is partly because I have become as tired of discussions of “full-time” teaching as I am of discussions of the Eighteenth Amendment, and partly because I do not think the issue is any longer of importance. There was a time when discussion of the system had a distinctly healthy effect on the teaching of medicine in America; but the whole situation is altered. A complete “full-time” system is impossible from an economic point of view, even if it were desirable medically, which I do not think it is. Experience has made it perfectly clear that the men who are in successful outside practice have something very definite and important to contribute to the teaching, and, as already indicated, they must be regarded as an integral part of the teaching service and receive proper recognition in the way of titles, salaries and clinical opportunities. I am, moreover, also convinced that it is not desirable to have any hard and fast rule as to the members of the hospital staff having private patients. For many, if not for all, it is desirable that they should have a few patients of their own, with whom they have the same relations that one does in outside practice. Occasional consultations, even outside the hospital, office practice and a few private patients in the hospital form the basis of a valuable experience for the teacher and investigator; but, of course, his other work will not allow him to assume the care of sick patients in their homes. There is no question in my own mind that I am a much better teacher for having had a limited number of such patients in recent years. These are the patients to whom I talk at length personally, and they are apt to be the cases that stick in my mind, so that I refer to them continually in talking to students. One can always say that the same thing may be done as well if the patients belong to the clinic and if, for instance, their fees are paid to the clinic; but I fear I do not agree to this. If they had been the patients of the clinic I should have had most of the work done by my assistants and I should have missed exactly that personal relationship with patients which many people say cannot be obtained in a hospital. If, however, I have been continually confronted with these personal relationships of practice, even though it be with few individuals at a time, it is much easier for me to keep accentuating their importance in the course of my work in the ward. In all of this, moreover, I do not believe that I am very different or more sordid in attitude than most men. It is not wholly a question of to whom the fees are paid (often there are no fees), although this certainly is a factor in establishing and maintaining the personal bond. The main point is that the patient has sought you or me personally and not the hospital.

In the last analysis, the whole problem resolves itself into what kind of men you select for the hospital staff. If they do the type of work they are expected to do, they can never see more than a very few private patients--fewer, indeed, than come now to the private wards of some “full-time” clinics. If they want to see more patients they must be transferred to the clinical staff. Practically, the issue has seemed to me to solve itself without presenting any great difficulties, and without resorting to an overorganization that limits the freedom of the individual. What we want is less of the system and law that kills and more of the spirit that gives life.